CHANGES IN MIDDLE CEREBRAL ARTERY VELOCITY WITH CAROTID CLAMPING : CORRELATION WITH STUMP PRESSURE

s of South West Vascular Surgeons Meeting held at St. Mary's Hospital, Portsmouth, 14 February 1992 PSEUDOXANTHOMA ELASTICUM CAUSING CLAUDICATION. W. G. Prout. Queen Alexandra Hospital, Portsmouth. Pseudoxanthoma elasticum is a heritable disorder of elastic fibre leading to characteristic skin changes, angioid occular streaking and cardio-vascular problems. A 34 year old man presenting with intermittent claudication is presented. The clinical presentation and pathogenesis of this rare condition are discussed. CHANGES IN MIDDLE CEREBRAL ARTERY VELOCITY WITH CAROTID CLAMPING: CORRELATION WITH STUMP PRESSURE. TP. Magee. A. H. Davies. J. Hayward, R. N. Baird, M. Horrocks Vascular Studies Unit, Bristol Royal Infirmary. ^he value of shunting and stump pressure measurement is controversial. Thirty six consecutive carotid endarterectomies have been studied prospectively. Middle cerebral artery velocity was Monitored intraoperatively in all patients and internal carotid artery stump pressure was measured at the time ot clamping. Stump pressure (rnmHg) 547 (47.6-81.7)* ?/? Stump pressure (/o of systemic) 45 7 (34.0-57.4)* v nica (change on clamping, cm/s) 14.9 (5.6-24.2)* The stump pressure measurements, whether expressed as an absolute or a percentage, did not correlate well with the change in Vmca on clamping (r = 0.359 and r = 0.258). As judged by transcranial Doppler, stump pressure measurement is a poor indicator of cerebral perfusion during carotid clamping. * = 95% confidence intervals. SPIRITUAL HEALING IN THE CONSERVATIVE MANAGEMENT OF VENOUS ULCERATION A. D. R. Northeast, and K. G. Burnand Surgical Unit, St. Thomas' Hospital, London. We compared the time to total healing of ulcers of proven venous aetiology, in a randomised single blind trial of compression bandaging with or without spiritual healing. Ischaemia, rheumatoid and sickle disease were excluded. Patients were managed with paste, Tensopress, and tubular bandages. The treated patients were then seen elsewhere by a Confederation of Healin? member.

Thirty six consecutive carotid endarterectomies have been studied prospectively. Middle cerebral artery velocity was Monitored intraoperatively in all patients and internal carotid artery stump pressure was measured at the time ot clamping. (change on clamping, cm/s) 14.9 (5.6-24.2)* The stump pressure measurements, whether expressed as an absolute or a percentage, did not correlate well with the change in Vmca on clamping (r = 0.359 and r = 0.258).
As judged by transcranial Doppler, stump pressure measurement is a poor indicator of cerebral perfusion during carotid clamping. We compared the time to total healing of ulcers of proven venous aetiology, in a randomised single blind trial of compression bandaging with or without spiritual healing.
Ischaemia, rheumatoid and sickle disease were excluded. Patients were managed with paste, Tensopress, and tubular bandages. The treated patients were then seen elsewhere by a Aortic aneurysmal disease may have a genetic basis for inheritance. We have studied the prevalence of aortic enlargement amongst first degree relatives of aneurysm patients to assess the suitability for screening.
First degree relatives of 100 consecutive abdominal aortic aneurysm patients were contacted. One hundred and four relatives (>50 yrs) were traced. Two (2%) had known aortic aneurysms. A further 76 (73%) proceeded to ultrasound scanning. In total, 9 of 39 males (23%) and 2 of 39 females (5%) were found to have enlarged aortas (AP diameter > 2.5cm). In conclusion we feel that male first degree relatives are an appropriate sub population for aortic aneurysm screening. This study examined quality of life a year or more after aortic grafting in 211 consecutive patients (186 male) aged 48-87 (median 74 years). There were 124 elective and 77 ruptured aneurym procedures. By the time of this review 165 patients were still alive, and 131 were interviewed (86 elective and 45 ruptured. The mental and physical state of patients was assessed using a Rosser index to calculate an average quality of life (QoL) score.
Those who had had elective aneurysm operations had similar QoL scores after operation as before, while scores were lower postoperatively in the ruptured aneurysm group. The commonest specific complaint was decreased sexual potency in men, affecting 38 (4) 14(1  15(0)  7(2) 14 (3) 19(2) 153(15) Of those with critical ischaemia the TH had more emergency referrals (59% vs 38%) and more with ulceration or gangrene (74% vs 44%). Severity of claudication was similar with just over half claudicating at less than 200 yds (58% TH vs 52% DGH). More patients with carotid disease or thoracic outlet syndrome were referred to the TH. Referrals from outside the direct catchment area were greater for TH (9.8% vs 1.6%). Both hospitals have similar investigation facilities but outpatient iv DSA is used more at the DGH and in-patient ia DSA at the TH. Over the same period 51 major vascular operations were carried out at the DGH and 84 at the TH, where there were more carotid endarterectomies (9 vs 0), distal bypasses (9 vs 0), re-explorations (10 vs 3) and a higher rate of vein usage for femoro-popliteal grafts (87% vs 41%). These results suggest that the more specialist vascular service available at the TH is provided largely to its local population. This audit of vascular surgery in a teaching hospital was facilitated by computerized data collection. A total of 2,075 patients had 2,628 procedures over the six year period [1985][1986][1987][1988][1989][1990].
Vascular workload increased by 50% over this period. Mean hospital stay is twice as long for vascular patients as general surgery patients (14 days vs 6 days).
The overall mortality was 10.4% ranging from 1.7% to 31.9%. Early re-operation for the complications of vascular reconstruction was required in 9.1%. Vascular surgery is expensive, time consuming and expanding. Audit is a pre-requisite for surgeons wishing to attract and maintain a vascular practice. Postoperative bleeding occurred early in 15 (3.0%), and later because of infection in 3 (0.6%). Early graft occlusion was seen in 2.9% aortofemoral, 10.3% femoropopliteal, and 24.0% femorotibial grafts. There was only 1 case of distal embolism after aortic surgery.
The overall incidence of amputation after grafting was 6.8%. An eighty-four year old female fractured her left humerous in a fall in 1991. In June 1991 she had one episode of ischaemia of the left hand treated with Heparin. In September 1991 further left hand ischaemia was treated with Heparin and in November 1991 further ischaemia and swelling of the left hand was associated with a large pulsating mass in the left shoulder. Exploration and radiology of the left axillary artery confirmed an aneurysm of the brachial artery. Following clot evacuation the bleeding was controlled proximally by a clamp and distally by a balloon catheter. The arteriotomy was closed 60 proline and the fracture edge excised for 2 cm. Following the repair of the artery the hand remained warm although the pressures were low. Function was normal. This case illustrates the late presentation of a false aneurysm but the warning signs of ischaemia were not investigated. Blood replacement in abdominal aortic aneurysm (AAA) repair places demands on blood bank resources and exposes patients to the risks of transfusion. To assess the feasibility of elective AAA repair without using homologous transfusion, ten consecutive patients each donated two units of blood over the two weeks preoperatively and had intraoperative blood loss salvaged with the Haemonetics Cell-Saver 111 plus.
The first two patients were mistakenly transfused in breach of the study protocol but none of the remaining patients has required homologous transfusion. We conclude that elective AAA repair can be safely performed without using homologous blood. In the absence of significant arteriosclerosis or cardiac disease limb loss is a rarity. Other causes including trauma, neoplasia congenital vascular and primary arterial wall abnormalities make up the remainder.
Major limb loss complicating inflammatory bowel disease (IBD) is an extreme rarity in the absence of the above. We present 2 patients aued 27 and 60 years, with IBD complicated by acute limb ischaemia resulting in forearm amputations and a review of the literature. During this 5 year period 212 patients underwent 230 primary major lower limb amputations. Eighteen lost both legs, an a further 13 became bilateral amputees (15% overall). Diabetics comprised 55% of the bilateral amputees, but only 33% of the tota' patient group.
Of patients alive at one month 66% were referred for limb fitting. Sixty nine patients fitted with prostheses were evaluated more than six months after amputation, and 52% were able to walk beyond their house and garden. occluded. Ninety one arteries were also examined with arteriography, with agreement in 86% of cases. Duplex missed 4 stenoses, but none were severe (>70%). Two occlusions were missed and 3 severely stenosed arteries were reported as occluded.
These scans have resulted in a total of 44 carotid endarterectoinies being performed. 20 on duplex findings alone and 24 after arteriographic confirmation. The majority of arteriograms were performed in the early days, but as confidence in the technique has increased, a greater proportion of surgery is now performed on duplex findings alone.